LABORATORY DIAGNOSIS SEXUALLY TRANSMITTED DISEASES

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LABORATORY DIAGNOSIS SEXUALLY TRANSMITTED
DISEASES

• LABORATORY
• MEDICINE COURSE
• 2004
• CLINICAL MICROBIOLOGY SERVICE
• Dr. Phyllis Della-Latta 52929

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STD EPIDEMIC- USATIP OF THE ICEBERG

• INCIDENCE
• DISCHARGE
• Chlamydia - 4 million
• Gonorrhea - 650,000
• Trichomoniasis - 180 million
• BV - Not reportable
• ULCERATIVE
• HPV - 5.5 million
• Herpes - 1 million
• Syphilis - 60,000

• CLINICAL IMPACT
• INFERTILITY
• ECTOPIC PREGNANCY
• HIV TRANSMISSION
• PID
• CERVICAL CA
• 10 BILLION ANNUAL COST

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STDs CLINICAL SYNDROMETHE HIDDEN EPIDEMIC

• AT RISK
• ADOLESCENTS MINORITIES
• MULTIPLE SEX PARTNERS
• PAST STDs

• DISCHARGE DISEASES
• HIV ACQUISITION ? 5- FOLD
• ULCERATIVE LESIONS/ GROWTHS
• HIV ACQUISITION ? 10- FOLD

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WOMEN AT RISK THE X FACTOR

• STDs OFTEN ASYMPTOMATIC
• 75-90 WOMEN WITH CHLAMYDIA
• 50-70 MEN WITH CHLAMYDIA
• PID
• ? 40 UNTREATED CASES GC/CHLAMYDIA
• INFERTILITY
• 1 IN 5 UNTREATED CASES
• CERVICAL CANCER
• AT- RISK PREGNANCIES

• PREMATURE LABOR DELIVERY
• LARGEST RATE OF INFANT MORTALITY
• PREMATURE RUPTURE OF MEMBRANES
• ECTOPIC PREGNANCIES
• NEONATES
• CONJUNCTIVITIS
• PNEUMONIA

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TEENS SEXSTD TESTS IN ADOLESCENT CLINICS

• AT-RISK GROUP
• MULTIPLE SEX PARTNERS
• UNPROTECTED SEX
• CONTRACEPTIVE USE INCONSISTENT
• THE X FACTOR FEMALES
• GC HIGHEST IN 15-19 YRS
• 5-10 TEENS CHLAMYDIA
• 28-46 lt25 YRS HPV
• SEX PARTNERS WITH OLDER MEN

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DISCHARGE DISEASES

• MOST COMMON DISCHARGE DISEASE IN U.S.
• CHLAMYDIA TRACHOMATIS
• NEISSERIA GONORRHAEAE
• TRICHOMONAS VAGINALIS
• RISK FACTORS
• YOUNG AGE
• MULTIPLE SEX PARTNERS
• PAST STDs

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GONORRHEA CHLAMYDIA

• CLINICAL SYNDROME
• SYMPTOMATIC OR ASYMPTOMATIC
• DYSURIA FREQUENCY
• PURULENT DISCHARGE INDISTINGUISHABLE
• GONORRHEA
• OTHER SITES (PHARYNX, RECTUM, EYE)
• NEWBORNS (PURULENT CONJUNCTIVITIS)
• BACTEREMIA, ARTHRITIS

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WHEN TO COLLECT ENDOCERVIX OR VAGINAL
SPECIMENS
ENDOCERVIX VAGINA
Normal pH 7.0 lt4.5
Cell Type COLUMNAR EPITHELIAL SQUAMOUS EPITHELIAL
Pathogens Chlamydia trachomatis Neisseria gonorrhoeae Bacterial Vaginosis (BV) Trichomonas Candida sp
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LAB DIAGNOSIS C. TRACHOMATIS

• NA AMPLIFICATION
• URINE SCREEN
• DIRECT FLUORESCENT AB
• DNA PROBES
• URETHRAL SPECIMEN
• TISSUE CULTURE
• McCOY CELLS
• INTRACYTOPLASMIC INCLUSIONS WITH
  IODINE
• IMMUNOFLUORESCENCE

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CT/GC LABORATORY DX
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CHLAMYDIA/GC URINE NAAT SCREEN

• NON-INVASIVE, PAINLESS!!!
• AUTOMATION
• TURNAROUND TIME
• 4 hrs
• SCREENING IS RECOMMENDED
• CDC, AMA, DOH
• MALES TEENS
• PREGNANCY

NAAT NUCLEIC ACID AMPLIFICATION TEST
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STD GUIDELINES - GC TESTINGCHILD ASSAULT CASES

• CULTURE - THE GOLD STANDARD
• PHARYNX ANUS IN MALES FEMALES
• VAGINA FEMALES
• URETHRA MALES
• NOT RECOMMENDED
• GRAM STAINS FOR DX
• NON-CULTURE TESTS
• NAAT DATA WONT HOLD UP IN COURT
• CERVICAL SPECIMENS FOR
  PRE-PUBERTAL GIRLS
• PHARYNGEAL SPECIMENS
• LACKS SENSITIVITY

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CDC GUIDELINES ADULTS CT GC TESTING

• CULTURES FROM ALL SITES OF PENETRATION
• OR
• FDA APPROVED NAAT
• 2 NAATs (different targets)
• both must be positive
• ASSAYS NOT APPROVED
• EIA, non-amplified probes, DFA
• Insensitive - False negatives

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CLINICAL SYNDROME COMPARISON
SYNDROME DISCHARGE ODOR PRESENTATION
Trichomonasis Watery, thin, gray, alkaline homogeneous FISHY Itching, vaginal erythema, dysuria, vaginal erosions, petechiae (strawberry cervix)
BACTERIAL VAGINOSIS Watery, gray, homogeneous alkaline FISHY Cervix normal,Often asymptomatic
CANDIDIASIS Thick, white, non-homogeneous SOUR Itching, vaginal erythema, dysuria, labial vulval swelling
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BRIEF CASES
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THE FISHY ODOR IN VIVO

• NORMAL VAGINAL FLORA
• H2O2 Producing Lactobacilli ? lactic acid
• ? pH (lt4.5)
• BACTERIAL VAGINOSIS
• Anaerobes Increase ? Proteolytic enzymes act on
  vaginal peptides
• Release of polyamines and trimethylamine
• Trimethylamine in alkaline pH ? fishy odor
• Polyamines ? Exfoliation of epithelial cells
• (clue cell)
• Polyamines ? Fishy discharge

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BV DIAGNOSED

• FACTS TO CONSIDER
• PREGNANT WOMEN
• AFFECT 15-20 PREGNANT WOMEN
• AMNIOTIC FLUID INFECTION
• POSTPARTUM ENDOMETRITIS
• PREMATURE RUPTURE OF
• MEMBRANES
• PRETERM DELIVERY
• LOW BIRTH WEIGHT
• TREAT PREGNANT WOMEN
• METRONIDAZOLE
• CLINDAMYCIN

BV ASSOCIATED WITH RECURRENT UTI PID POST-OP GYN
INFECTIONS
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TRICHOMONAS VAGINITISLAB TESTS

• WET MOUNT
• URINE OR VAGINAL SECRETION MUST BE VIEWED
  IMMEDIATELY
• TRANSPORT INSTABILITY
• lt50 SENSITIVITY/SPECIFICITY
• TIME TO RESULTS 5-10 MINUTES
• IN-POUCH CULTURE
• NO SPECIMEN TRANSPORT PROBLEM
• DIRECT INOCULATION INTO POUCH PARASITE GROWS IN
  MEDIA
• gt95 SENSITIVITY/SPECIFICITY
• TIME TO RESULTS 18-48 HRS

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TRICHOMONAS DX

• FACTS TO CONSIDER
• THIRD MOST COMMON OF THE VAGINITIDES
• THOUGHT TO FACILITATE HIV TRANSMISSION
• PREVALENCE
• COMMERCIAL SEX WORKERS, 50-75
• (TRICKY BUSINESS)
• STD CLINICS, 32-54
• OB CLINICS, 10-26
• TREATMENT
• METRONIDAZOLE

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VULVOVAGINAL CANDIDASIS

• ETIOLOGIC AGENT
• 85-95 CANDIDA ALBICANS
• CANDIDA GLABRATA
• LESS SUSCEPTIBLE TO AZOLES
• HIV INFECTED
• FREQUENCY
• 70-75 AT LEAST ONCE
• 40-50 RECURRENCE
• PREDISPOSING FACTORS
• ANTIBIOTICS, DIABETES
• ORAL CONTRACEPTIVES

• WHAT TESTS SHOULD BE ORDERED?
• GRAM STAIN
• CULTURE ONLY WHEN RECURRENT INFECTIONS
• YEAST IS NORMAL FLORA
• DNA PROBE TEST

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ULCERATIVE DISEASES

• INCIDENCE
• gt20 MILLION CASES
• ETIOLOGIC AGENTS
• HERPES SIMPLEX VIRUS
• TREPONEMA PALLIDUM
• HUMAN PAPILLOMA VIRUS
• CHANCROID
• CONTRIBUTE TO HIV TRANSMISSION
• ULCER IS PORTAL OF ENTRY

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SYPHILIS

• Incidence
• Increase in NYC among men who have sex with men
  (MSM)
• WHITE MEN THOSE IN MANHATTAN
• LARGELY HIV INDICATING EROSION OF SAFE SEX
• Higher in the south
• HETEROSEXUAL BLACK MEN
• Primary Syphilis CHANCRE
• Single, Painless, Smooth edges, Indurated, LA
• Secondary Syphilis
• Palmar rash
• 6 wk-6 mth after infection

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LAB DX - SYPHILIS

• MICROSCOPIC (primary)
• DARK FIELD
• TREPONEMA PALLIDUM
• MOTILE SPIROCHETE
• (6-14 SPIRALS)
• SEROLOGY (secondary)
• RPR (rapid plasma reagin)
• FTA (fluorescent treponemal Ab)
• Confirmatory test
• VDRL - CSF
• UNCULTURABLE

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LAB DX - SYPHILIS
TEST ANTIGEN INTERPRETATION
VDRL (CSF) Screen CARDIOLIPIN CHOLESTEROL TRUE POSITIVE RPR TITER gt12 VDRL TITER gt12 FALSE POSITIVE Autoimmune diseases Infectious mono Pregnancy, Old age
RPR Screen CARDIOLIPIN CHOLESTEROL TRUE POSITIVE RPR TITER gt12 VDRL TITER gt12 FALSE POSITIVE Autoimmune diseases Infectious mono Pregnancy, Old age
FTA-AB confirmatory T. pallidum FLUORESCENCE
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SEROLOGIC TESTS FOR SYPHILIS
TEST SENSITIVITY BY STAGE OF SYPHILIS () SENSITIVITY BY STAGE OF SYPHILIS () SENSITIVITY BY STAGE OF SYPHILIS () SENSITIVITY BY STAGE OF SYPHILIS () SPECIFICITY ()
TEST 10 20 LATENT LATE SPECIFICITY ()
VDRL 78 (74-87) 100 95 (88-100) 71 (37-94) 98 (96-99)
RPR 86 (77-100) 100 98 (95-100) 73 98 (93-99)
FTA-ABS 84 (70-100) 100 100 96 97 (94-100)
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HERPES SIMPLEXLAB DX

• DIRECT IMMUNOFLUORESCENCE
• SCRAPE CELLS OFF BASE OF ULCER STAIN
• DIFFERENTIATES TYPES 1 2
• CULTURE
• SHELL VIAL
• CYTOPATHOGENIC EFFECT
• SENSITIVITY 70-99, SPECIFICITY 99
• CYTOLOGY H E STAIN
• MULTI-NUCLEATED GIANT CELLS
• SENSITIVITY SPECIFICITY lt60
• PCR
• INVESTIGATIONAL
• DIFFERENTIATES TYPES 1 2

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LAB DX - HPV

• HYBRID CAPTURE PROBE
• Sensitivity 84-100
• Specificity 74-95
• PCR FROM CERVICAL SPECIMENS
• DX IS OFTEN CLINICAL

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HUMAN PAPILLOMA VIRUS

• INCIDENCE
• MOST PREVALENT STD IN COLLEGE WOMEN
• CLINICAL IMPRESSION
• VISIBLE GENITAL WARTS CALLED CONDYLOMA ACUMINATA
• CONDYLOMA KNUCKLES, ACUMINATA POINTED
• SMOOTH OR FINGERLIKE FLESH-COLORED PROJECTIONS ?
  ROUGH
• MULTIPLE PAPULES MAY BECOME CONFLUENT, OR
  MULTILOBED MASSES
• CAN BE PAINFUL, FRIABLE /OR PRURITIC
• INVASIVE CANCER
• 16,18, 31, 33 35 TYPES CARRY HIGH TO MODERATE
  RISK